Along with the NHS and wider healthcare system, we are changing the way we investigate patient safety incidents or patient safety events. 

The Patient Safety Incident Response Framework (PSIRF), will soon replace the previous Serious Incident (SI) approach to dealing with patient safety incidents. It will be more flexible, transparent, and compassionate in its approach to learning responses and investigations. The focus will be on understanding the different factors that contributed to the incident and ensuring that we all learn from them.

NHS England states that there are four key aims of PSIRF:

1. Compassionate engagement and involvement of those affected by patient safety incidents. Listening to patients, families and staff involved in incidents with respect and care and involving them meaningfully throughout the process.
2. Application of a range of system-based approaches to learning from patient safety incidents. Using tools to help understand all the different factors at play that have come together to contribute to the incident.
3. Considered and proportionate responses to patient safety incidents. Making sure the organisation chooses actions that are appropriate to help understand what happened, learn from it and to reduce the risk of future harm.
4. Supportive oversight focused on strengthening response system functioning and improvement. Making sure patient safety managers and leaders help all staff apply the lessons learned from incident reviews and investigations so that the team and wider organisation work in a safer way. Making sure this insight is shared for wider learning in local and national systems.

PSIRF will encompass different learning responses following a patient safety event. Some examples are:

• Swarm huddle—this involves colleagues ‘swarming’ to the site of an incident as soon as possible to analyse what happened, understand how it happened and decide what needs to be done to reduce the risk of it happening again.
• After Action Reviews (AARs)—a technique used to capture learning from an activity or event that has that has gone well or has resulted in patient harm.
• Thematic reviews—which aim to identify patterns in data to help answer questions, show links or identify issues.
• Patient Safety Incident Investigation (PSII)—an investigation that takes place when an incident or near-miss has significant patient safety risks and the potential for new learning.

Head of Quality and Patient Safety, Sharon Cundy, said: “We are currently in a transitional stage, and we want all our colleagues to be comfortable and prepared for this exciting new chapter in patient safety.

“Whilst the NHSE guidance advised a launch in 2023, we wanted to be assured that colleagues were trained in certain PSIRF requirements before the transition commenced?

“PSIRF will apply to all our colleagues in whatever role they have, and training is currently underway covering various aspects of the new framework. 

“There is already an Essential Safety Training course for all colleagues in ESR called: Patient Safety Level 1 - Essentials for all staff. 

“And our Quality and Safety team are currently arranging engagement and drop-in sessions. Once the dates are confirmed we’ll share them with colleagues.  There will also be a dedicated intranet page where you will find various documents in relation to our PSIRF journey.

For any questions or queries, please email: patientexperience@cht.nhs.uk